Knowledge Base Article

Did You Know?

February is American Heart Month. Per NCD 210.11 (link), cardiovascular disease (CVD):

• Is the leading cause of mortality in the United States,
• Is comprised of hypertension, coronary artery disease (i.e., myocardial infarction and angina pectoris), heart failure and stroke, and
• Is the leading cause of hospitalizations.

Risk Factors for CVD includes:

• Being overweight,
• Obesity,
• Physical inactivity,
• Diabetes,
• Cigarette smoking,
• High Blood Pressure (HTN),
• High blood cholesterol,
• Family history of myocardial infarction, and
• Older age

Why this Matters?

Annually, the CERT publishes a supplemental improper payment data report. Table D4, in the supplemental report (link), highlights the top 20 service types with the highest improper payments for Part A IPPS Hospitals. This table also details the percentage of error by each of the CERT’s major error categories:

• No documentation,
• Insufficient documentation,
• Medical necessity.
• Incorrect coding, and
• Other.

In the 2021 supplemental data, nine of the top twenty service types with highest improper payments were DRGs in the major diagnostic category (MDC) 5 Diseases and Disorders of the Circulatory System. Insufficient documentation and medical necessity were the two most common type of errors cited for this group of service types.

The projected improper payment for the circulatory system service types is $714,632,739 representing 36% of the total projected improper payments for the top twenty service types.

What Can You Do?

Be proactive for your patients by becoming familiar with the cardiovascular disease screening tests and intensive behavioral therapy for cardiovascular disease covered by Medicare and additional resources published in the February 10, 2022 edition of MLN Connects (link):

• Preventive Services webpage (link)
• Achieving Health Equity web-based training (link)
• CMS Office of Minority Health, Health Observances webpage (link)
• Million Hearts® (link): HHS initiative to prevent a million heart attacks and strokes
• Cardiovascular disease screenings coverage (link) & behavioral therapy (link): information for your patients

Become familiar with coverage determinations related to the top services. For example:

• For DRGs 226 and 227 (Cardiac Defibrillator Implant without cardiac catheterization with MCC and without MCC respectively), there is a National Coverage Determination (NCD 20.4) and Medicare Administrative Contractor (MAC) specific Local Coding and Billing Articles.
• Transcatheter Aortic Valve Replacement (TAVR) and TEER (Transcatheter Edge-to-Edge Repair) procedures fall within DRGs 266 and 267. Both procedures have a related NCD (TAVR NCD 20.32 and TEER NCD 20.33).
• Percutaneous Left Atrial Appendage Closure (LAAC) procedures fall within DRGs 273 and 274 and has a related NCD (20.34).
• For DRG 313 (Chest Pain), Palmetto GBA the Jurisdiction J and M MAC, has a Local Coverage Determination (LCD L34551) titled, One Day Stays for Chest Pain.

Finally, respond to requests for documentation in a timely manner, sending adequate documentation to support the medical necessity of the services provided.